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PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGE IN THE MATTER OF THE MINOR SETTLEMENT OF_____________________________________ CASE NO. ______________________ WAIVER AND CONSENT TO SETTLE MINOR'S CLAIM The undersigned, waive all claims for damages on account of loss of services of said minor, waive notice of the hearing, and consent to and approve the Form 22.0, Application to Settle Minor's Claim, a copy of which is attached hereto. Typed or Printed Name Typed or Printed Name Typed or Printed Name Typed or Printed Name Typed or Printed Name Typed or Printed Name Typed or Printed Name Typed or Printed Name «NTU33/2T- FORM 22.1 ­ WAIVER AND CONSENT TO SETTLE MINOR'S CLAIM (MODIFIED) American LegalNet, Inc. www.FormsWorkFlow.com 4/97